Even first-line treatments could be rendered ineffective

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A substantial portion of E. coli urinary tract infections (UTIs) in children were resistant to commonly used antibiotics, both in first world countries and less developed parts of the world.

Note that the Infectious Diseases Society of America (ISDA) and the European Society for Clinical Microbiology and Infectious Diseases state that in order for an antibiotic to be considered a first-line treatment for a UTI, resistance should not exceed 20% in the most likely infecting strain.

A substantial portion of E. coli urinary tract infections (UTIs) in children were resistant to commonly used antibiotics, both in first world countries and less developed parts of the world, according to a meta-analysis.

In an analysis of 58 studies from 26 countries that documented antibiotic resistance in pediatric UTIs, resistance rates to ampicillin, cotrimoxazole, and trimethoprim in first world countries came in at 53.4% (95% CI 46.0-60.8), 30.2% (95% CI 20.5-39.3) and 23.6% (95% CI 13.9-32.3) pooled resistance, respectively, reported Ashley Bryce, a PhD candidate at the University of Bristol in England, and colleagues.

In developing countries, pooled resistance was 79.8% (95% CI 73.0-87.7) to ampicillin, 69.6% to cotrimoxazole (95% CI 59.8-81.5), and 60.3% to co-amoxiclav (95% CI 40.9-79.0), they wrote in The BMJ.

"This could render some antibiotics ineffective as first line treatments," the authors wrote.

A dozen studies that specifically examined children ages 0-5 years found even higher rates of antibiotic resistance, especially in the five studies from non-OCED countries. The pooled resistance to ampicillin jumped to 90.3%, while resistance to cotrimoxazole and co-amoxiclav was over 70% each.

Andrew Pavia, MD, of the University of Utah in Salt Lake City, told MedPage Today via e-mail that in some regions, commonly used antibiotics are becoming less useful for treating UTIs.

"Importantly, this study helps confirm that routine use of antibiotics in a child not only contributes to antibiotic resistance in the population, but increases the risk of an antibiotic resistant infection for that child," said Pavia, who was not involved in the study. "It is striking how high the antibiotic-resistance of E. coli-causing UTIs in children has become and how widespread the problem is."

Bryce's group examined five studies that found children who had recently received antibiotics had a particular strain of E. coli that was up to 13 times more likely to show resistance to antibiotics. In some cases, this increase in risk persisted up to 6 months ((OR 13.23, 95% CI 7.84-22.31).

However, the authors noted that the OR may have been affected by one study that measured exposure to antibiotics for a combined total of 4 weeks or more within the previous 6 months compared with no exposure within those months. By contrast, the other four studies measured exposure within an undefined combined length of time versus no prescriptions.

Other study limitations included the fact that antibiotic use differs by country, and over-the-counter use is difficult to measure. They also pointed out that other factors may have contributed to the prevalence of resistance in certain countries, such as sanitation issues, unstable governments, and fewer regulations in medicine.

An accompanying editorial by Grant Russell, PhD, of Monash University in Melbourne, Australia noted that the study results from Bryce's group may force clinicians to make a change in how they deal with their pediatric patients who present with infections.

"Primary care clinicians will probably need to get used to taking an 'antibiotic history' before prescribing for common bacterial infections," Russell wrote. "A parent's claim that 'antibiotic x always works for my child' might need to be balanced with the notion that 'if antibiotic x was used in the last six months, there's a good chance it's not going to work as well if used again."

Bryce disclosed support from the National Institute for Health Research (NIHR) School for Primary Care Research. One co-author disclosed support from NIHR.

Bryce and co-authors disclosed no relevant relationships with industry.

Russell disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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